Coder's Cranium / General / Hot Coding Topics / Provider News

Stop Forfeiting Level Four and Five E/Ms With 3 PFSH Tips

Make your physician’s job easier by letting the patient or nurse document the history.

If your physician glosses over a patient’s past, family, and social history (PFSH), you may be missing out on up to $69 per E/M.  Accurately counting the number of PFSH items could result in more money for an encounter, because the top-level E/M codes require PFSH elements in addition to an extended history of present illness, and more than 1 system reviewed. Learn these three quick tips to ensure your physician is capturing, and you’re recognizing, every history component the patient mentions.

1. Determine the Level of PFSH

For coding purposes, the history portion of an E/M service requires all three elements — history of present illness (HPI), review of systems (ROS), and a past, family and social history (PFSH).  Therefore, the PFSH helps determine patient history level, which has a great effect on the E/M level you can report.  If you do not know the PFSH level, you may have to select a lower level of E/M service than might otherwise be warranted.  There are three levels of PFSH: none, pertinent, and complete, says Leah Gross, CPC, coding lead at Metro Urology in St. Paul, Minn.

Pertinent: To reach a detailed level of history for the encounter (in addition to an extended HPI and the review of 2-9 systems), you need a pertinent PFSH.  According to Medicare’s Documentation Guidelines for E/M Services, you need at least one specific item from any of the three PFSH areas to achieve the pertinent level.  When the physician asks only about one history area related to the main problem, this is a pertinent PFSH.

Complete: To reach a comprehensive level of history for the encounter (in addition to an extended HPI and the...

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June 8, 2011
CMS / Provider News

CMS: Prove Your Exemption From the E-Prescribing Penalty With New G Codes

Even if you don’t have prescribing privileges, you can rest assured now as CMS will not cut your pay as a penalty for failing to comply with the new e-prescribing incentive program.

As you are probably aware, starting in 2012, you may be subject to a one percent payment adjustment on your Part B pay if you don’t successfully participate in e-prescribing this year. In 2013, that payment adjustment will go up to 1.5 percent, and in 2014 it will rise to two percent, CMS’s Daniel Green, MD noted on a Feb. 15 CMS-sponsored call.

“To earn an incentive in 2011, an eligible professional must e-prescribe 25 times during the year, ten of which must be in the first six months,” Green said. “If they are a successful e-prescriber during the calendar year, they not only would avoid the 2012 payment adjustment, they would get a one percent 2011 payment incentive, and they would be exempt from the 2013 payment adjustment,” he explained.

“Earning an incentive in 2011 does not necessarily exempt the eligible professional or group practice from a payment adjustment in 2012,” Green explained.

How to Avoid the Adjustment

CMS reps said that they’ve been flooded with calls about the 2012 payment adjustment, and described ways that you can avoid the adjustment if you qualify.

Not eligible to prescribe: If you are not a physician, nurse practitioner, or physician assistant between Jan. 1 and June 30, 2011, you can avoid the e-prescribing penalty. In addition, if you don’t have prescribing privileges at least once on a claim between Jan. 1 and June 30, 2011, you should append G8644 (Eligible professional does not have prescribing privileges) at least once before June 30 to ensure that your MAC knows you are not subject to the penalty, said CMS’s Michelle...

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March 27, 2011
Hot Coding Topics / modifier 25

AK Removals: Earn $120 by Following 17000-17111 with 99201

Stick to these 3 tips for your E/M and lesion removal procedures.

You can report both the E/M and lesion removal if the E/M service was a significant and separately identifiable service for an E/M service with actinic keratoses (AK) removal procedure.

Always verify with your carrier before appending modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the E/M code.

You can only consider reporting modifier 25 when coding an E/M service, says Janet Palazzo, CPC, coder for a practice in Cherry Hill, N.J. If the procedures you are reporting don’t fall under E/M services, it is possible the encounter qualifies for another modifier instead.

Have a look at the following three tips to help you report these services accurately so your practice won’t miss out on about $41 for 99201 and $80 for 17000 or more, according to national averages indicated in Medicare’s 2011 Physician Fee Schedule.

1. Know When You Should Charge an E/M

Each insurer has its own guidelines for office visits (99201- 99215, Office or other outpatient visit …) and lesion removals (17000-17111, Destruction, Benign or Premalignant Lesions). So, knowing whether to appeal an E/M denial is difficult unless you know that the service deserves payment.

You should report the office visit (99201-99215) in addition to the procedure when the dermatologist performs a significant, separately identifiable E/M service from the AK removal, especially if the patient is new to your practice.

Along with the appropriate E/M code, report any diagnoses that come with that examination, which may include more than just the AK.

For example, if a patient comes in for an initial AK visit, you should charge an E/M service, since the physician has to examine the area and discuss...

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March 21, 2011
Provider News

HHA Referral: More Documentation Requirements Add to Physician Burden

Agencies will have little control over new physician-related payment condition. Home health agencies are hoping for some big changes to one troublesome provision in the 2011 proposed payment rule – the face-to-face physician encounter requirement.

The mandate for the face-to-face encounter was in the Patient Protection and Affordable Care Act health care reform law enacted earlier this year. But the CMS version of the requirement is even stricter than the law requires.

Example: The proposed rule also requires that the encounter be for the primary reason home care services are required and that physicians furnish “unprecedented” physician documentation about the encounter and why the patient meets homebound criteria. “We believe that CMS has gone beyond statutory intent” in those two provisions, says the National Association for Home Care & Hospice.

The proposed face-to-face encounter requirement is riddled with problems for HHAs, industry experts say. To begin with, agencies have little influence over whether their patients make it to the doctor for a visit.

“It is absolutely ridiculous to place a requirement on home health providers for which they have absolutely no control,” protests consultant Pam Warmack with Clinic Connections in Ruston, La. “How in the world is the staff of the home health provider supposed to ensure that the patient visits the physician and that the physician documents appropriately in his/her office records?” Warmack asks.

“We can make appointments for patients, but we can’t ensure they keep them, that their transportation is reliable, that they feel well enough to make the trip, etc.,” Warmack continues. “There are so, so many reasons that patients fail to see the physician despite the best efforts of the home care staff to make it happen.”

The requirement will be “a particular burden on home health patients who are homebound and have difficulty leaving home,” notes...

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September 20, 2010
Coding Challenge / modifier 53

Oncology Coding: Determine the Proper Adverse Reaction Code

Remember to describe all the circumstances surrounding a push to get full reimbursement.

Question: If a non-Hodgkin’s lymphoma patient has an adverse reaction to Rituximab less than 15 minutes into the ordered hour-long infusion, should I report a push?

Answer: Experts suggest the most appropriate way to report a discontinued infusion is to append modifier 53 (Discontinued procedure) to the appropriate chemotherapy infusion code, such as 96413 (Chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug).

You should use modifier 53 when a physician stops a procedure “due to extenuating circumstances or those that threaten the well-being of the patient,” according to CPT.

Modifier 53 describes an unexpected problem, beyond the physician’s or patient’s control, that necessitates ending the procedure. The physician doesn’t elect to discontinue the procedure as much as he is forced to do so because of the circumstances.

Push: CPT guidelines include “an infusion of 15 minutes or less” as one definition of a push, but 96413-53 describes the ordered and provided service more accurately than a push code (such as 96409, Chemotherapy administration; intravenous, push technique, single or initial substance/drug).

HCPCS: Your documentation should describe the circumstances, the administration start and stop times, and the amount of drug delivered and discarded. If you’re coding for the drug (J9310, Injection, rituximab, 100 mg), you should be able to report the entire amount, assuming you discarded the amount not administered.

ICD-9: Remember also to report the appropriate ICD- 9 codes, such as V58.12 (Encounter for antineoplastic immunotherapy) and 202.8x (Other lymphomas), and a code to indicate why the procedure stopped, such as V64.1 (Surgical or other procedure not carried out because of contraindication) or E933.1 (Drugs, medicinal, and biological substances causing adverse effects in therapeutic use; antineoplastic and immunosuppressive drugs).

Also watch for...

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June 3, 2010
Coding Challenge / ICD-10 / ICD-9

Coding Generalized Bronchitis? Prepare for Denials

Relying on the physician’s encounter form could be a big mistake.

Question: I used 491.9 to report a patient’s bronchitis, but the payer denied my claim and requested additional information. What was wrong?

Vermont Subscriber

Answer: Your claim may have...

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March 23, 2010
Coding Challenge / ICD-10 / ICD-9

Ob-gyn Coding Challenge: Deliver Postpartum V Codes With Care

Bonus: Get exposure to ICD-10 coding equivalents.

Question: A mentally-challenged patient who delivered at home was admitted to the hospital for postpartum care. The patient delivered the placenta at home, and once admitted, she had no complications, but the ob-gyn…

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March 10, 2010
Coding Challenge / E/M

EM Coding: Should I Select 99211 for Most Med Checks?

Insurers might want to see a clear explanation as to why the E/M was necessary.

Question: An established patient with a plan of care in place for her gastroesophageal reflux disease (GERD) reports to the gastroenterologist; two weeks ago, the…

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March 6, 2010
Coding Challenge

Counseling Must Dominate Exception Claims For Seamless Payment

Choose the service level using the documented history, exam, and MDM. Question: A new patient with a chronic gastric ulcer meets the gastroenterologist for management of her condition. The gastroenterologist meets for 34 minutes with the patient, and performs an expanded problem focused history and exam and straightforward medical decision making. The note also indicate that [...] Related articles:

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February 25, 2010
Coding Challenge / E/M / modifier 25

Gastroenterology Coding Challenge: Repositioning a G Tube

Reading 44373’s code descriptor is key to getting your G Tube claim right. Question: The gastroenterologist goes to the hospital to treat a patient that had recently been admitted because his gastrojejunostomy tube had migrated to his stomach. After performing a problem focused interval history and exam, the gastroenterologist decides to perform an EGD to reposition the [...] Related articles:

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February 7, 2010
Coding Challenge / E/M

Is E/M Possible Pre-Colonoscopy?

Question: A local family physician refers a patient to our gastroenterologist for a diagnostic colonoscopy. The patient reports to the practice and meets the gastroenterologist for the first time. After answering some patient questions during a brief introduction, the gastroenterologist performs a diagnostic colonoscopy with brushing. The patient had never met the gastroenterologist before. Is the time he spent with the patient [...] Related articles:

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February 3, 2010
CMS / Coding Challenge / E/M

E/M Challenge: Can I Report 99214 and +99354?

Counseling representing more than 50 percent of E/M visit? Choose level based on time. Question: I have a family physician who documented 60 minutes on an established patient’s office visit. The FP diagnosed the patient with morbid obesity (278.01). Since the patient was newly diagnosed and had some difficulty understanding the doctor’s orders, the FP spent [...] Related articles:

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January 31, 2010
Coding Challenge / modifier 25

10060 Won’t Wash for Some I&Ds

Careful: A pilonidal cyst I&D is a separate animal. Question: A patient presents to the ED reporting pain in her spine. During the exam portion of a level-three E/M, the physician discovers that the painful area is red, and slightly warm to the touch. The patient also has a low-grade fever that she says she noticed about [...] Related articles:

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January 14, 2010
CPT 2010 / Provider News

CPT 2010 Update: Non-Face-to-Face Prolonged Services

New Year’s hats & horns for looser guidelines that let you count work spread over days. Groaning thinking of all the time you’ll never capture for complex cases requiring extensive pre-visit time? CPT 2010 brings you hope. Extensive guideline revisions “liberalize prolonged non-face-to-face services codes,” reports Richard Tuck, MD, FAAP, pediatrician at PrimeCare of Southeastern Ohio in [...] Related articles:

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November 5, 2009
Coding Challenge / E/M

Does My E/M Coding Have to Match Hospital’s E/M Coding?

Question: My physician removed a catheter in an outpatient hospital exam room. Should I include this removal as part of the E/M? If E/M is appropriate, will the hospital also report an E/M? And, if so, do the physician and hospital E/M codes need to match? Answer: You should include simple Foley catheter removal as part [...] Related articles:

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October 28, 2009